<!DOCTYPE html>
<html lang="en" xmlns:th="http://www.thymeleaf.org">
<head>
    <meta charset="UTF-8">
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</head>
<body>
<div><h3 align="center" style="margin-bottom: 40px;">祝您早日康</h3> </div>
<hr>
<form  action="/appointnow" class="form-horizontal" >

    <div class="form-group" style="margin-bottom: 40px; margin-top: 40px;" >
        <label for="name1" class="col-md-1 control-label col-md-offset-3">姓名</label>
        <div class="col-md-2">
            <input type="text" class="form-control" name="name" placeholder="name" id="name1" th:value="*{name}"/>
        </div>
        <label for="id1" class="col-md-1 control-label">性别</label>
        <div class="col-md-2">
            <select class="form-control" name="sex" id="id1">
                <option value="男" >男</option>
                <option  value="女" >女</option>
            </select>
        </div>
    </div>

    <div class="form-group"  style="margin-bottom: 40px;">
        <label for="pphone1"   class="col-md-1 control-label col-md-offset-3">本人电话</label>
        <div class="col-md-2">
            <input type="tel" onkeyup="value=value.replace(/[^\d]/g,'')" maxlength="11" class="form-control" name="pphone" placeholder="pphone" id="pphone1" th:value="*{pphone}"/>
        </div>
        <label for="ophone1" class="col-md-1 control-label" >亲友电话</label>
        <div class="col-md-2">
            <input type="tel"  onkeyup="value=value.replace(/[^\d]/g,'')"  maxlength=11 class="form-control" name="ophone" placeholder="ophone" id="ophone1" th:value="*{ophone}"/>
        </div>
    </div>

    <div class="form-group"  style="margin-bottom: 40px;">
        <label for="age1" class="col-md-1 control-label col-md-offset-3">年龄</label>
        <div class="col-md-2">
            <input type="tel"  onkeyup="value=value.replace(/[^\d]/g,'')"  maxlength=3 class="form-control" name="age"required="ture" placeholder="age" id="age1" th:value="*{age}"/>
            <!-- <input type="number" maxlength=3 class="form-control" name="age" placeholder="age" required="ture" id="age1" th:value="*{age}"/> -->
        </div>
        <label for="ethnic1" class="col-md-1 control-label" >民族</label>
        <div class="col-md-2">
            <input type="text" class="form-control" name="nation" placeholder="ethnic" id="ethnic1" th:value="*{ethnic}"/>
        </div>
    </div>

    <div class="form-group"  style="margin-bottom: 40px;">

        <label for="blood1" class="col-md-1 control-label col-md-offset-3">血型</label>
        <div class="radio col-md-2" id="blood1">
            <label>
                <input type="radio" name="bloodshape" value="A型" aria-label="..." />A型
            </label>
            <label>
                <input type="radio" name="bloodshape" value="B型" aria-label="..."  />B型
            </label>
            <label>
                <input type="radio" name="bloodshape" value="O型" aria-label="..." />O型
            </label>
            <label>
                <input type="radio" name="bloodshape" value="AB型" aria-label="..." />AB型
            </label>
            <label>
                <input type="radio" name="bloodshape" value="不详" aria-label="..."/>不详
            </label>
        </div>
        <label for="orderdata1" class="col-md-1 control-label" >预约日期</label>
        <div class="col-md-2 ">
            <input type="date" class="form-control" name="appointdata" placeholder="orderdata" id="orderdata1" />
        </div>
    </div>
    <div class="form-group"  style="margin-bottom: 40px;">
        <label for="casehistory1" class="col-md-1 control-label col-md-offset-3">预约需求</label>
        <textarea class="form-control col-md-offset-4" style="width: 40%;" rows="6" name="appointneed" placeholder="简述您的具体需求" required="ture" id="casehistory1"></textarea>
    </div>

    <div class="form-group"  style="margin-bottom: 40px;">
        <div class="container">
            <center>
                <button type="submit" class="btn btn-primary" onclick="">提交预约</button>
            </center>
        </div>
    </div>
</form>

</body>

<script>

</script>
</html>
